Abstract Context Miniaturized instruments for percutaneous nephrolithotomy (PNL), utilizing tracts sized ≤22 Fr, have been developed in an effort to reduce the morbidity and increase the efficiency ...of stone removal compared with standard PNL (>22 Fr). Objective We systematically reviewed all available evidence on the efficacy and safety of miniaturized PNL for removing renal calculi. Evidence acquisition The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Since it was not possible to perform a meta-analysis, the data were summarized in a narrative synthesis. Evidence synthesis After screening 2945 abstracts, 18 studies were included (two randomized controlled trials RCTs, six nonrandomized comparative studies, and 10 case series). Thirteen studies were full-text articles and five were only available as congress abstracts. The size of tracts used in miniaturized procedures ranged from 22 Fr to 4.8 Fr. The largest mean stone size treated using small instruments was 980 mm2 . Stone-free rates were comparable in miniaturized and standard PNL procedures. Procedures performed with small instruments tended to be associated with significantly lower blood loss, while the procedure duration tended to be significantly longer. Other complications were not notably different between PNL types. Study designs and populations were heterogeneous. Study limitations included selection and outcome reporting bias, as well as a lack of information on relevant confounding factors. Conclusions The studies suggest that miniaturized PNL is at least as efficacious and safe as standard PNL for the removal of renal calculi. However, the quality of the evidence was poor, drawn mainly from small studies, the majority of which were single-arm case series, and only two of which were RCTs. Furthermore, the tract sizes used and types of stones treated were heterogeneous. Hence, the risks of bias and confounding were high, highlighting the need for more reliable data from RCTs. Patient summary Removing kidney stones via percutaneous nephrolithotomy (PNL) using smaller sized instruments (mini-PNL) appears to be as effective and safe as using larger (traditional) instruments, but more clinical research is needed.
Bladder stones (BS) constitute 5% of urinary stones. Currently, there is no systematic review of their treatment.
To assess the efficacy (primary outcome: stone-free rate SFR) and morbidity of BS ...treatments.
This systematic review was conducted in accordance with the European Association of Urology Guidelines Office. Database searches (1970–2019) were screened, abstracted, and assessed for risk of bias for comparative randomised controlled trials (RCTs) and nonrandomised studies (NRSs) with ≥10 patients per group. Quality of evidence (QoE) was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool.
A total of 2742 abstracts and 59 full-text articles were assessed, and 25 studies (2340 patients) were included. In adults, one RCT found a lower SFR following shock wave lithotripsy (SWL) than transurethral cystolithotripsy (TUCL; risk ratio 0.88, p=0.03; low QoE). Four RCTs compared TUCL versus percutaneous cystolithotripsy (PCCL): meta-analyses demonstrated no difference in SFR, but hospital stay (mean difference MD 0.82d, p<0.00001) and procedure duration (MD 9.83min, p<0.00001) favoured TUCL (moderate QoE). Four NRSs comparing open cystolithotomy (CL) versus TUCL or PCCL found no difference in SFR; hospital stay and procedure duration favoured endoscopic surgery (very low QoE). Four RCTs compared TUCL using a nephroscope versus a cystoscope: meta-analyses demonstrated no difference in SFR; procedure duration favoured the use of a nephroscope (MD 22.74min, p<0.00001; moderate QoE). In children, one NRS showed a lower SFR following SWL than TUCL or CL. Two NRSs comparing CL versus TUCL/PCCL found similar SFRs; catheterisation time and hospital stay favoured endoscopic treatments. One RCT comparing laser versus pneumatic TUCL found no difference in SFR. One large NRS comparing CL techniques found a shorter hospital stay after tubeless CL in selected cases; QoE was very low.
Current available evidence indicates that TUCL is the intervention of choice for BSs in adults and children, where feasible. Further high-quality research on the topic is required.
We examined the literature to determine the most effective and least harmful procedures for bladder stones in adults and children. The results suggest that endoscopic surgery is equally effective as open surgery. It is unclear whether stone size affects outcomes. Shock wave lithotripsy appears to be less effective. Endoscopic treatments appear to have shorter catheterisation time and convalescence compared with open surgery in adults and children. Transurethral surgery, where feasible, appears to have a shorter hospital stay than percutaneous surgery. Further research is required to clarify the efficacy of minimally invasive treatments for larger stones and in young children.
Endoscopic treatments offer a shorter hospital stay and recovery than open surgery, with an equivalent stone-free rate (SFR). Transurethral cystolithotripsy is quicker with a continuous flow instrument and offers a shorter hospital stay compared with percutaneous cystolithotripsy. Shock wave lithotripsy appears to offer an inferior SFR.
The European Association of Urology urolithiasis guidelines indicate that follow-up beyond 2–3 yr is not required for post-treatment stone-free urolithiasis patients. Non–stone-free patients could be ...discharged or reoperated based on the residual fragment size. Adherence to metabolic treatment frees patients from follow-up at 36–48 mo.
No algorithm exists for structured follow-up of urolithiasis patients.
To provide a discharge time point during follow-up of urolithiasis patients after treatment.
We performed a systematic review of PubMed/Medline, EMBASE, Cochrane Library, clinicaltrials.gov, and reference lists according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Fifty studies were eligible.
From a pooled analysis of 5467 stone-free patients, we estimated that for a safety margin of 80% for remaining stone free, patients should be followed up using imaging, for at least 2 yr (radiopaque stones) or 3 yr (radiolucent stones) before being discharged. Patients should be discharged after 5 yr of no recurrence with a safety margin of 90%. Regarding residual disease, patients with fragments ≤4 mm could be offered surveillance up to 4 yr since intervention rates range between 17% and 29%, disease progression between 9% and 34%, and spontaneous passage between 21% and 34% at 49 mo. Patients with larger residual fragments should be offered further definitive intervention since intervention rates are high (24–100%). Insufficient data exist for high-risk patients, but the current literature dictates that patients who are adherent to targeted medical treatment seem to experience less stone growth or regrowth of residual fragments, and may be discharged after 36–48 mo of nonprogressive disease on imaging.
This systematic review and meta-analysis indicates that stone-free patients with radiopaque or radiolucent stones should be followed up to 2 or 3 yr, respectively. In patients with residual fragments ≤4 mm, surveillance or intervention can be advised according to patient preferences and characteristics, while for those with larger residual fragments, reintervention should be scheduled.
Here, we review the literature regarding follow-up of urolithiasis patients. Patients who have no stones after treatment should be seen up to 2–3 yr, those with large fragments should be reoperated, and those with small fragments could be offered surveillance with imaging.
Abstract Context An optimum metabolic evaluation strategy for urinary stone patients has not been clearly defined. Objective To evaluate the optimum strategy for metabolic stone evaluation and ...management to prevent recurrent urinary stones. Evidence acquisition Several databases were searched to identify studies on the metabolic evaluation and prevention of stone recurrence in urolithiasis patients. Special interest was given to the level of evidence in the existing literature. Evidence synthesis Reliable stone analysis and basic metabolic evaluation are highly recommended in all patients after stone passage (grade A). Every patient should be assigned to a low- or high-risk group for stone formation. It is highly recommended that low-risk stone formers follow general fluid and nutritional intake guidelines, as well as lifestyle-related preventative measures to reduce stone recurrences (grade A). High-risk stone formers should undergo specific metabolic evaluation with 24-h urine collection (grade A). More specifically, there is strong evidence to recommend pharmacological treatment of calcium oxalate stones in patients with specific abnormalities in urine composition (grades A and B). Treatment of calcium phosphate stones using thiazides is only highly recommended when hypercalciuria is present (grade A). In the presence of renal tubular acidosis (RTA), potassium citrate and/or thiazide are highly recommended based on the relative urinary risk factor (grade A or B). Recommendations for therapeutic measures for the remaining stone types are based on low evidence (grade C or B following panel consensus). Diagnostic and therapeutic algorithms are presented for all stone types based on the best level of existing evidence. Conclusion Metabolic stone evaluation is highly recommended to prevent stone recurrences. Patient summary In this report, we looked at how patients with urolithiasis should be evaluated and treated in order to prevent new stone formation. Stone type determination and specific blood and urine analysis are needed to guide patient treatment.
Abstract Context Management of urinary stones is a major issue for most urologists. Treatment modalities are minimally invasive and include extracorporeal shockwave lithotripsy (SWL), ureteroscopy ...(URS), and percutaneous nephrolithotomy (PNL). Technological advances and changing treatment patterns have had an impact on current treatment recommendations, which have clearly shifted towards endourologic procedures. These guidelines describe recent recommendations on treatment indications and the choice of modality for ureteral and renal calculi. Objective To evaluate the optimal measures for treatment of urinary stone disease. Evidence acquisition Several databases were searched to identify studies on interventional treatment of urolithiasis, with special attention to the level of evidence. Evidence synthesis Treatment decisions are made individually according to stone size, location, and (if known) composition, as well as patient preference and local expertise. Treatment recommendations have shifted to endourologic procedures such as URS and PNL, and SWL has lost its place as the first-line modality for many indications despite its proven efficacy. Open and laparoscopic techniques are restricted to limited indications. Best clinical practice standards have been established for all treatments, making all options minimally invasive with low complication rates. Conclusion Active treatment of urolithiasis is currently a minimally invasive intervention, with preference for endourologic techniques. Patient summary For active removal of stones from the kidney or ureter, technological advances have made it possible to use less invasive surgical techniques. These interventions are safe and are generally associated with shorter recovery times and less discomfort for the patient.
Abstract Context Low-dose computed tomography (CT) has become the first choice for detection of ureteral calculi. Conservative observational management of renal stones is possible, although the ...availability of minimally invasive treatment often leads to active treatment. Acute renal colic due to ureteral stone obstruction is an emergency that requires immediate pain management. Medical expulsive therapy (MET) for ureteral stones can support spontaneous passage in the absence of complicating factors. These guidelines summarise current recommendations for imaging, pain management, conservative treatment, and MET for renal and ureteral stones. Oral chemolysis is an option for uric acid stones. Objective To evaluate the optimal measures for diagnosis and conservative and medical treatment of urolithiasis. Evidence acquisition Several databases were searched for studies on imaging, pain management, observation, and MET for urolithiasis, with particular attention to the level of evidence. Evidence synthesis Most patients with urolithiasis present with typical colic symptoms, but stones in the renal calices remain asymptomatic. Routine evaluation includes ultrasound imaging as the first-line modality. In acute disease, low-dose CT is the method of choice. Ureteral stones <6 mm can pass spontaneously in well-controlled patients. Sufficient pain management is mandatory in acute renal colic. MET, usually with α-receptor antagonists, facilitates stone passage and reduces the need for analgesia. Contrast imaging is advised for accurate determination of the renal anatomy. Asymptomatic calyceal stones may be observed via active surveillance. Conclusions Diagnosis, observational management, and medical treatment of urinary calculi are routine measures. Diagnosis is rapid using low-dose CT. However, radiation exposure is a limitation. Active treatment might not be necessary, especially for stones in the lower pole. MET is recommended to support spontaneous stone expulsion. Patient summary For stones in the lower pole of the kidney, treatment may be postponed if there are no complaints. Pharmacological treatment may promote spontaneous stone passage.
Urolithiasis is a clinical condition showing increasing trends, especially among European and other developed countries. The European Association of Urology (EAU), in close collaboration with experts ...in the field, publishes a yearly updated clinical guideline, in order to provide practicing urologists around Europe and the rest of the world a tool for optimizing patient care and decision-making. The methodological approach for developing this guide is quite rigorous and follows rigorous scientific standards. The challenges that a urologist faces are increasing; therefore, during meticulous literature search, the EAU Urolithiasis Panel identifies gaps in knowledge and conducts systematic reviews, in order to provide answers or to propose ideas for designing future research. This way, a new section was published last year, regarding diagnosis and management of bladder stones, with more systematic reviews on the way. The aim of this study is to analyze current structure and goals of the EAU Urolithiasis Panel, along with future ambitions and challenges.
Increasing trends in kidney stone disease along with developments in technology necessitate systematic organization of information for urologists in order to be able to follow diagnostic and therapeutic algorithms for optimizing patient care. The role of the European Association of Urology Urolithiasis Guideline Panel is to provide such a tool by development of urolithiasis guidelines on an annual basis.
The European Association of Urology Guidelines Panel works constantly to improve the evidence supporting the created recommendations on different topics of urolithiasis. The involvement of a nephrologist expert, a patient representative, and new young associate members is the new addition to the panel human resources. Improving the evidence by conducting systematic reviews on several topics and even supporting randomized trials in the future is the next goal.
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